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Preferred Gold with and without Part D (HMO-POS)

2018 Plan Highlights	Co-pay/Co-insurance
Preferred Gold with Part D monthly premium with prescription drug coverage	$172.20
Preferred Gold with Part D monthly premium for EPIC subsidy members (Assumes EPIC premium assistance)	$133.20
Preferred Gold without Part D monthly premium without prescription drug coverage**	$59.20
Annual Out-of-Pocket Max for your protection (once met, MVP pays 100% of covered services)	$6,700 Excluding acupuncture, eye wear, and Part D drug costs
PCP co-pay	$15
Specialist co-pay	$30
Inpatient Hospital co-pay	$350/day for days 1-5; $0 for days 6+
Emergency Room Care (Worldwide Coverage)	$80
Urgently Needed Care (Worldwide Coverage)	$50
Lab	$10
X-rays	$30
Other radiology services (CT scan, PET scan, MRI)	$60
Skilled nursing facility	$0/day for days 1-20, $167/day for days 21-100, or until out-of-pocket max is met
Outpatient services co-pay	$100 Ambulatory, $225 Outpatient Hospital
Home care	Covered in full
Diabetic blood glucose test strips	10% co-insurance for OneTouch, FreeStyle, and Precision brands
TruHearing^® Hearing Aid Benefit	$499 or $799 co-pay per aid with Part D $699 or $999 co-pay per aid without Part D Up to two aids per year
Eye wear	$125 allowance every 2 years with Part D $100 allowance every 2 years without Part D
Out of network coverage	30%; $2,500/yr max
Wellness Rewards^sm	$75 reward per year
SilverSneakers fitness program - fitness center membership benefits
myVisitNow^SM Access 24/7 online doctor visits using a computer, tablet, or smart phone.	$15-$30
Dental*	$240 allowance per year for preventive dental services Preferred Gold with Part D only.

** Note: If you do not join a Medicare Part D plan when you first become eligible, or do not have coverage as good as Medicare's (creditable coverage) you may have to pay a penalty if you join Part D at a later date.

Part D Prescription Drug Coverage (for Preferred Gold with Part D)
Find a Drug - 2018 Comprehensive Medicare Part D Covered Drugs (Formulary) Preferred Gold with Part D offers the convenience of both medical and Part D prescription drug coverage together in one plan. Do not join a separate Part D plan for your prescription drug coverage. If you do, Medicare will disenroll you out of your MVP plan. MVP's coverage for medically necessary Medicare Part D approved drugs includes:
Initial Coverage Stage During this stage, you pay your Tier co-pay or co-insurance for covered prescription drugs.	Retail Pharmacy (30 day supply)	CVS Caremark Mail Order (90 day supply)
Tier 1 - Preferred Generic Drugs	$0	$0
Tier 2 - Generic Drugs	$10	$20
Tier 3 - Preferred Brand Name Drugs	$35	$70
Tier 4 - Non-Preferred Brand Drugs	36%	36%
Tier 5 - Specialty Drugs	33%	Not Available
Not all Part D drugs are available through the mail.
Coverage Gap Stage	Once your total drug expenses in 2018 reach $3,750, you will pay 44% for generic drugs, 35% for Medicare-contracted brands, 100% for non-Medicare contracted brands. You will continue to pay $0 for Tier 1 drugs.
Catastrophic Coverage Stage	When you have paid $5,000 out of pocket in 2018, your cost for prescriptions is reduced to the greater of 5% or $3.35 for generics and $8.35 for brand-name drugs.
Part D drugs excluded from our Formulary must go through an exception process in order to be covered. If they are approved, they will be covered in Tier 4.
Non-Part D drugs are not covered.
Note: Costs for Part B drugs and supplies are 20%. Drugs purchased outside the U.S. are not Medicare approved and are not covered.

HMO-POS members may see doctors within and outside the MVP network. However, with the exception of emergencies or urgent care, it will cost more to get care from out-of-network providers. You must use network pharmacies to access your prescription drug benefit.

Last Updated: October 2017

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Important Information

MVP Health Plan, Inc. is an HMO-POS/PPO/MSA organization with a Medicare contract. Enrollment in MVP Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Out-of-network/non-contracted providers are under no obligation to treat MVP Health Plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Medicare beneficiaries may also enroll in Preferred Gold HMO-POS, GoldValue HMO-POS, GoldSecure HMO-POS, Gold PPO, BasiCare PPO, and/or WellSelect PPO through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Y0051_3606 Approved